Utility of urgent colonoscopy in acute lower gastro-intestinal bleeding: a single-center experience

Abstract

Background. The role of urgent colonoscopy in lower gastro-intestinal bleeding (LGIB) remains controversial. Over the last two decades, a number of studies have indicated that urgent colonoscopy may facilitate the identification and treatment of bleeding lesions; however, studies comparing this approach to elective colonoscopy for LGIB are limited.Aims. To determine the utility and assess the outcome of urgent colonoscopy as the initial test for patients admitted to the intensive care unit (ICU) with acute LGIB.Methods. Consecutive patients who underwent colonoscopy at our institution for the initial evaluation of acute LGIB between January 2011 and January 2012 were analysed retrospectively. Patients were grouped into urgent vs. elective colonoscopy, depending on the timing of colonoscopy after admission to the ICU. Urgent colonoscopy was defined as being performed within 24 hours of admission and those performed later than 24 hours were considered elective. Outcomes included length of hospital stay, early re-bleeding rates, and the need for additional diagnostic or therapeutic interventions. Multivariable logistic regression analysis was performed to identify factors associated with increased transfusion requirements.Results. Fifty-seven patients underwent colonoscopy for the evaluation of suspected LGIB, 24 of which were urgent. There was no significant difference in patient demographics, co-morbidities, or medications between the two groups. Patients who underwent urgent colonoscopy were more likely to present with hemodynamic instability (P = 0.019) and require blood transfusions (P = 0.003). No significant differences in length of hospital stay, re-bleeding rates, or the need for additional diagnostic or therapeutic interventions were found. Patients requiring blood transfusions (n = 27) were more likely to be female (P = 0.016) and diabetics (P = 0.015). Fourteen patients re-bled at a median of 2 days after index colonoscopy. Those with hemodynamic instability were more likely to re-bleed [HR 3.8 (CI 1.06–13.7)], undergo angiography [HR 9.8 (CI 1.8–54.1)], require surgery [HR 13.5 (CI 3.2–56.5)], and had an increased length of hospital stay [HR 1.1 (1.05–1.2)].Conclusion: The use of urgent colonoscopy, as an initial approach to investigate acute LGIB, did not result in significant differences in length of ICU stay, re-bleeding rates, the need for additional diagnostic or therapeutic interventions, or 30-day mortality compared with elective colonoscopy. In a pre-specified subgroup analysis, patients with hemodynamic instability were more likely to re-bleed after index colonoscopy, to require additional interventions (angiography or surgery) and had increased length of hospital stay.

Urgent colonoscopy in patients with lower GI bleeding: a systematic review and meta-analysis

“…Additionally, we performed 4 secondary analyses in an attempt to reduce bias, reduce heterogeneity among the included studies, and increase statistical robustness. Studies were categorized and analyzed as (1) prospective studies (which included randomized controlled trials 7,8 and Jensen et al 18 and Nagata et al, 13 which used propensity score matching), (2) retrospective studies, [9][10][11][12][13][14][15][16][17] (3) retrospective cohort studies (excluding the Nagata et al 13 study), [9][10][11][12][14][15][16][17] and (4) all studies (but excluded the Navaneethan et al 14 study because it used a large administrative database and was heavily weighted in the analysis). [7][8][9][10][11][12][13][15][16][17][18] All meta-analyses were performed using the random effects model.…”

“…A total of 12 studies met our inclusion criteria, and the characteristics of the included studies are summarized in Table 1. [7][8][9][10][11][12][13][14][15][16][17][18] Nine studies occurred in the United States, [7][8][9][10][11]14,[16][17][18] with 3 studies occurring outside of the United States: 1 in Spain 12 and 2 in Japan. 13,15 Most studies were retrospective cohort studies 9-17 followed by 2 randomized controlled trials 7,8 and 1 prospective cohort study.…”

“…Figure 3 displays the results of the meta-analysis that examined the use of therapeutic interventions in urgent versus elective colonoscopy. [7][8][9][12][13][14]16,17 Our meta-analysis determined that there was a 70% greater use of therapeutic interventions in patients with LGIB who underwent urgent versus elective colonoscopy (RR, 1.70; 95% CI, 1.08-2.67; I 2 Z 73.2%; P < .001 for heterogeneity; Fig. 3A).…”

“…The most common endoscopic techniques that were reported in the examined studies included epinephrine injection, thermal contact modalities, and endoscopic clips; there was no difference in use of specific therapies or devices in patients who underwent either urgent or elective colonoscopy. 9 Additional clinical outcomes: transfusion rates, adverse events, rebleeding, and mortality A number of other important clinical outcomes were assessed with few differences noted between urgent and elective colonoscopy ( Table 2 and Supplementary Fig. 1).…”

Diagnostic and therapeutic treatment modalities for acute lower gastrointestinal bleeding: a systematic review

“…Case definitions of LGIB are included in Appendix 2 . A total of 11 studies included patients with LGIB of any cause 4 18 19 20 23 24 25 26 27 28 29 and four were limited to patients with diverticular bleeding 17 21 22 30 . The number of participants enrolled in each study ranged from 72 to 100 in the RCTs, and from 27 to 326 in the NRSIs.…”